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530 Prematurity and Fetal Growth: “Normal” Weights Based on Abnormal Pregnancies
Volume 166 Number 1, Part 2
528
PREDICTION OF LONG TERM NEUROLOGIC HANDICAP IN VERY LOll BIRTINEI6HT NEWIIORIIS FL Gaudier: RL Goldenberg, M Peralta: KG Nelson: M DuBard: SE Johnson: RA Steele: TY Roth' University of Alabama Hospitals, Birmingham, Alabama lhi s study was performed to determi ne if factors other than low BWT predict neurologic handicap. 310 infants with a BWl of 500-1000 gms who deli vered between 1979-89, with a 1ast evaluation at >1 year of age were studied. The factors studied included BWT, GA, Apgar score, and umbilical arterial cord gases including pH, HCO" pCO, and pO,. Outcomes evaluated included mental retardation (MR) defined as an 10 <70 on the last 10 test performed, cerebral palsy (CP), and any major handicap (MH) including MR, CP, blindness, deafness and hydrocephalus. BWl was not associated with any of the outcomes studied, while the GA was inversely associated with CP (p=.05) and MH (p=.02). Both I and 5 minute Apgar scores were associated with MR (p=.02) and MH (p=.02). Both high and low pH values were associated with CP and (p=.003) and MH (p=.OOI). As an example, 5 of the 6 infants with a pH <7 had a MH (p<.OOI) compared to 20% with a pH >7 and <7.35. Of infants with a pH of >7.35,50% had a MH (p<.OOOI). Levels of HCO, were inversely associated with all 3 outcomes (p~.OI). As an example, a HCO, of !26 was associated with 9% MH while a HCO, <14 was associated with 54% MH. Both hi gh and low 1eve 1s of 0, and CO, were assoc i ated wi th the 3 poor outcomes. Regression analyses, controlling for GA, BWT. 5 minute Apgar score and type of anesthesia were performed to confi rm the re 1at i onshi ps between cord gases and outcome described above. As an example, the Odds Ratios (OR) for MH associated with a pH <7 was 4.1 and the OR for MH for a pH >7.35 was 3.9 compared to a pH of 7 to 7.35. The OR for MH for a HCO, <13 compared to a HCO, of >23 was 6.4. The U-shaped relationship between both high and low CO, and 0, and MH was confi rmed. In sumnary. cord gas measurements are highl y predictive of long term neurologic handicap in very low birthweight infants, but the relationships are more complex than originally anticipated.
529
OBSTETRIC PREDICTION OF THE SYMPTOMATIC GROWTH RETARDED NEONATE. H.M. Wolfe, M.P. Dombrowski, R.J. Sokol, Y.W. Brans", Dept. of OblGyn, Hutzel Hosp./Wayne State Univ., Detroit, MI Studies suggest that weight for length (w II). rather than birthweight percentile (bwt%) may be more sensitive for the identification of symptomatic IUGR. We studied 12,238 non-LGA near term births (~ 36 wks) to compare the utility of measures of growth (w/l, bwt%, wll for gestational age and birthweight (bwt)) in the prediction of six adverse growth-related neonatal outcomes. By multivariate analysis, overall morbidity was best predicted by wi!. WII (not adjusted for gestational age) showed the strongest association with hypoglycemia, low 5 minute apgar score and polycythemia. Only meconium aspiration was better predicted when w/l was adjusted for gestational age (w/l/gal. No significant relation was found between cesarean section for fetal distress or need for resuscitation and any measure of growth. The most significant predictor of 416 outcomes was wll, with only a small amount of additional variance explained by bwt%. These findings are consistent with the supposition that symptomatic IUGR is related to in utero caloric deprivation as reflected in decreased w II. Since adjustment for gestational age adds little to the prediction of adverse outcomes in the near term infant, initial identification of the high risk neonate can be expediently made in the delivery room by the simple process of assessing neonatal weight and length. Further evaluation of the low wll near term infant by the pediatrician should include assessment of bwt%.
SPO Abstracts
530 PREMATURITI' AND FETAL GROWTH: 'NORMAL' WEIGHTS BASED ON ABNORMAL PREGNANCIES. SF Bottoms/IE Zador, and KL Chan. Wayne State Univ., Hutzel Hospital, Detroit, MI. Currently the same proportion (10%) of preterm and term are classified as SGA. Consequently "normal" birth weight standards for preterm infants are based exclusively on data from abnormal births (prematures). Recent studies suggest that preterm delivery is associated with diminished fetal growth. The purpose of this study is to develop birth weight norms based on the entire population, including the normal undelivered fetus. We studied 4653 consecutive singleton live births having complete ultrasound examinations and delivering at our hospital from 1983-1988, excluding major congenital malformations. Gestational age at time of ultrasound was calculated based on pediatric examination. There was no significant difference between mean EFW and mean birth weight for the 479 premature infants who delivered within 3 days of ultrasound. EFW percentiles based on the entire population were developed for each week from 26-36 weeks. Classification based on these tables according to gestational age at delive.!Y,ls summanze . d below. Preterm Term SGA 100(20.9%) 332(8.0%) AGA 351(73.3%) 3406(81.6%) LGA 436JlO.40/<>1 ~60/ol .. Growth claSSIfIcation of preterm mfants based on EFW differed from that of term infants (p < 0.0001), and from current birth weight classification (p < 0.0001). We conclude that current growth classification systematically underestimates the relative frequency of diminished growth among preterm infants as compared to those delivered at term.
531 FETAL AND NEONATAL HEMATOLOGIC PARAMETERS IN RED CELL ALLOIMMUNIZATlON: PREDICTING THE NEED Fot! NEONATAL TOP-UP TRANSFUSION. George R. Saade. M.D. x , Kenneth J. Moise, Jr., M.D., Michael A. Selfort, M.D." Diane Hesketh, R.N." Robert J. Carpenter, Jr., M.D.; Dept. of Ob/Gyn; Saylor College of Medicine; Houston, Tx. Recently, there has been an increased awareness for the need for tOP-l4l transfusion (lUT) in neonates treated with intrauterine transfusion (JUT) for red cell alloilllllJnization. Purplse: To determine whether any fetal or neonatal hematologic parameter can be used to predi ct the need for TUT. Material and Methods: The records of 36 patients who underwent JUT's and had adequate neonatal follow-up were reviewed. The patients 2 that needed TUT were coorpared to those that did not using x and unpaired Student t test. Results: No statistically significant difference was found between the two groups in the IllI1'ber of lUTs or neonatal exchange transfusions, the gestationaL age at first JUT, the presence or absence of hydrops, the fetal hct or hgb at the last JUT, and the ",*,il ical cord retic count or bilirubin. Fetuses who required TUT had a lower retic count at their last JUT (1.5 ! 2.3 vs 4.9 :!: 4.8 %; P = .01) and longer duration between their lowest retic count and del ivery (42.1 :!: 23.5 vs 24.3 :!: 17.6 days; P = .03). In addition, these newborns had a higher ",*,ilical cord hgb (13.5:!: 1.7 vs 11.0:!: 2.3 gm %; P < .01) and % adult red cells (96.0 :!: 7.7 vs 82.5 :!: 19.6; p = .02). None of the newborns with a cord hgb < 11.8 gm% requi red lUT. Concl .... ions: lhe data suggests that the need for lUT is related to the extent and duration of fetal bone marrow suppression caused by transfusion of adult cells in utero.
419
528
PREDICTION OF LONG TERM NEUROLOGIC HANDICAP IN VERY LOll BIRTINEI6HT NEWIIORIIS FL Gaudier: RL Goldenberg, M Peralta: KG Nelson: M DuBard: SE Johnson: RA Steele: TY Roth' University of Alabama Hospitals, Birmingham, Alabama lhi s study was performed to determi ne if factors other than low BWT predict neurologic handicap. 310 infants with a BWl of 500-1000 gms who deli vered between 1979-89, with a 1ast evaluation at >1 year of age were studied. The factors studied included BWT, GA, Apgar score, and umbilical arterial cord gases including pH, HCO" pCO, and pO,. Outcomes evaluated included mental retardation (MR) defined as an 10 <70 on the last 10 test performed, cerebral palsy (CP), and any major handicap (MH) including MR, CP, blindness, deafness and hydrocephalus. BWl was not associated with any of the outcomes studied, while the GA was inversely associated with CP (p=.05) and MH (p=.02). Both I and 5 minute Apgar scores were associated with MR (p=.02) and MH (p=.02). Both high and low pH values were associated with CP and (p=.003) and MH (p=.OOI). As an example, 5 of the 6 infants with a pH <7 had a MH (p<.OOI) compared to 20% with a pH >7 and <7.35. Of infants with a pH of >7.35,50% had a MH (p<.OOOI). Levels of HCO, were inversely associated with all 3 outcomes (p~.OI). As an example, a HCO, of !26 was associated with 9% MH while a HCO, <14 was associated with 54% MH. Both hi gh and low 1eve 1s of 0, and CO, were assoc i ated wi th the 3 poor outcomes. Regression analyses, controlling for GA, BWT. 5 minute Apgar score and type of anesthesia were performed to confi rm the re 1at i onshi ps between cord gases and outcome described above. As an example, the Odds Ratios (OR) for MH associated with a pH <7 was 4.1 and the OR for MH for a pH >7.35 was 3.9 compared to a pH of 7 to 7.35. The OR for MH for a HCO, <13 compared to a HCO, of >23 was 6.4. The U-shaped relationship between both high and low CO, and 0, and MH was confi rmed. In sumnary. cord gas measurements are highl y predictive of long term neurologic handicap in very low birthweight infants, but the relationships are more complex than originally anticipated.
529
OBSTETRIC PREDICTION OF THE SYMPTOMATIC GROWTH RETARDED NEONATE. H.M. Wolfe, M.P. Dombrowski, R.J. Sokol, Y.W. Brans", Dept. of OblGyn, Hutzel Hosp./Wayne State Univ., Detroit, MI Studies suggest that weight for length (w II). rather than birthweight percentile (bwt%) may be more sensitive for the identification of symptomatic IUGR. We studied 12,238 non-LGA near term births (~ 36 wks) to compare the utility of measures of growth (w/l, bwt%, wll for gestational age and birthweight (bwt)) in the prediction of six adverse growth-related neonatal outcomes. By multivariate analysis, overall morbidity was best predicted by wi!. WII (not adjusted for gestational age) showed the strongest association with hypoglycemia, low 5 minute apgar score and polycythemia. Only meconium aspiration was better predicted when w/l was adjusted for gestational age (w/l/gal. No significant relation was found between cesarean section for fetal distress or need for resuscitation and any measure of growth. The most significant predictor of 416 outcomes was wll, with only a small amount of additional variance explained by bwt%. These findings are consistent with the supposition that symptomatic IUGR is related to in utero caloric deprivation as reflected in decreased w II. Since adjustment for gestational age adds little to the prediction of adverse outcomes in the near term infant, initial identification of the high risk neonate can be expediently made in the delivery room by the simple process of assessing neonatal weight and length. Further evaluation of the low wll near term infant by the pediatrician should include assessment of bwt%.
SPO Abstracts
530 PREMATURITI' AND FETAL GROWTH: 'NORMAL' WEIGHTS BASED ON ABNORMAL PREGNANCIES. SF Bottoms/IE Zador, and KL Chan. Wayne State Univ., Hutzel Hospital, Detroit, MI. Currently the same proportion (10%) of preterm and term are classified as SGA. Consequently "normal" birth weight standards for preterm infants are based exclusively on data from abnormal births (prematures). Recent studies suggest that preterm delivery is associated with diminished fetal growth. The purpose of this study is to develop birth weight norms based on the entire population, including the normal undelivered fetus. We studied 4653 consecutive singleton live births having complete ultrasound examinations and delivering at our hospital from 1983-1988, excluding major congenital malformations. Gestational age at time of ultrasound was calculated based on pediatric examination. There was no significant difference between mean EFW and mean birth weight for the 479 premature infants who delivered within 3 days of ultrasound. EFW percentiles based on the entire population were developed for each week from 26-36 weeks. Classification based on these tables according to gestational age at delive.!Y,ls summanze . d below. Preterm Term SGA 100(20.9%) 332(8.0%) AGA 351(73.3%) 3406(81.6%) LGA 436JlO.40/<>1 ~60/ol .. Growth claSSIfIcation of preterm mfants based on EFW differed from that of term infants (p < 0.0001), and from current birth weight classification (p < 0.0001). We conclude that current growth classification systematically underestimates the relative frequency of diminished growth among preterm infants as compared to those delivered at term.
531 FETAL AND NEONATAL HEMATOLOGIC PARAMETERS IN RED CELL ALLOIMMUNIZATlON: PREDICTING THE NEED Fot! NEONATAL TOP-UP TRANSFUSION. George R. Saade. M.D. x , Kenneth J. Moise, Jr., M.D., Michael A. Selfort, M.D." Diane Hesketh, R.N." Robert J. Carpenter, Jr., M.D.; Dept. of Ob/Gyn; Saylor College of Medicine; Houston, Tx. Recently, there has been an increased awareness for the need for tOP-l4l transfusion (lUT) in neonates treated with intrauterine transfusion (JUT) for red cell alloilllllJnization. Purplse: To determine whether any fetal or neonatal hematologic parameter can be used to predi ct the need for TUT. Material and Methods: The records of 36 patients who underwent JUT's and had adequate neonatal follow-up were reviewed. The patients 2 that needed TUT were coorpared to those that did not using x and unpaired Student t test. Results: No statistically significant difference was found between the two groups in the IllI1'ber of lUTs or neonatal exchange transfusions, the gestationaL age at first JUT, the presence or absence of hydrops, the fetal hct or hgb at the last JUT, and the ",*,il ical cord retic count or bilirubin. Fetuses who required TUT had a lower retic count at their last JUT (1.5 ! 2.3 vs 4.9 :!: 4.8 %; P = .01) and longer duration between their lowest retic count and del ivery (42.1 :!: 23.5 vs 24.3 :!: 17.6 days; P = .03). In addition, these newborns had a higher ",*,ilical cord hgb (13.5:!: 1.7 vs 11.0:!: 2.3 gm %; P < .01) and % adult red cells (96.0 :!: 7.7 vs 82.5 :!: 19.6; p = .02). None of the newborns with a cord hgb < 11.8 gm% requi red lUT. Concl .... ions: lhe data suggests that the need for lUT is related to the extent and duration of fetal bone marrow suppression caused by transfusion of adult cells in utero.
419